1. Spectrum of Radiologic Findings for Pulmonary Aspergillosis X. Gallardo, E. Casta ñ er, J.M. Mata, F. Novell, M. Andreu

2. Introduction Aspergillosis is a mycotic disease caused usually by Aspergillus fumigatus. Aspergillus is a ubiquitous soil fungi. The manifestations of pulmonary aspergillosis are determined by the number and virulence of the organisms and the patient’s immune response.

3. Pulmonary Aspergillosis Categories Hypersensitivity Normal Immunosuppression Allergic Bronchopulmonary Aspergillosis Aspergilloma Semi-invasive Aspergillosis Acute Tracheobronchitis Bronchiolitis Bronchopneumonia Angioinvasive Aspergillosis Chronic illness Corticosteroids COPD Neutropenia

4. It is found in patients with long-standing bronchial asthma. Is caused by an hypersensitivity reaction. The fungi proliferate in the airway lumen. Immune complexes and inflammatory cells produce bronchial wall damage and then bronchiectasis and mucous plugs containing Aspergillus hyphae. Clinical symptoms: wheezing, malaise, low-grade fever, cough, sputum production, and recurrent pneumonia. Allergic Bronchopulmonary Aspergillosis

5. Imaging findings. a) Bronchiectasis involving predominantly the upper lobes (arrows). b) Tubular opacities related to plugging of airways by hyphal masses with mucoid impaction (arrows). These lesions can migrate from one region to another. a b Allergic Bronchopulmonary Aspergillosis

6. Imaging findings. Same patient CT scan. CT images better demostrate the bronchiectasis involving the upper right lobe (a) and some months later filled by mucoid impaction (b). ab Allergic Bronchopulmonary Aspergillosis

7. Imaging findings. The impacted mucus can has high attenuation or calcification at CT. In this case there is evidence of air-trapping secondary to bronchial obstruction (arrows). Allergic Bronchopulmonary Aspergillosis

8. Is an Aspergillus infection without tissue invasion. Correspond a conglomeration of fungal hyphae admixed with mucus and cellular debris within a preexistent pulmonary cavity The most common underlying causes are tuberculosis and sarcoidosis. Clinical symptoms: usually asymptomatic, the most common clinical manifestation is hemoptysis. Aspergilloma

9. Imaging findings. Aspergilloma formation. Patient with a tuberculous cavity in the upper left lobe. a) Initial apparition of lineal opacities in the cavity corresponding to aspergillus hyphae. b) Progressive growing of the fungi almost filling the cavity. c) Oval mass with soft-tissue opacity separated from the wall of the cavity by an airspace ( “ air crescent ” sign). d) Finally the mass separated from de cavity walls moves with the changes position of the patient. abcd Aspergilloma

10. Imaging findings. Chronic lesions and tuberculous cavity in the upper left lobe. Thickening of the cavity wall or adjacent pleura may be the earliest radiographic sign in Aspergillomas formation (arrows). Approximately 10% of mycetomas resolve spontaneously. Reversibility of the pleural thickening may indicate the resolution of intracavitary fungal colonization. Aspergilloma

11. Imaging findings. CT scan of the same patient shows thickening of the cavity wall and initial formation of an Aspergilloma (b). Aspergilloma ab

12. Is one of the Airway-invasive aspergillosis. Is characterized by the presence of Aspergillus organisms deep within the airway wall. It occurs most commonly in neutropenic patients and in patients with AIDS. Clinical symptoms: are those of acute tracheobronchitis (dry cough, low fever, chest pain). Acute Tracheobronchitis

13. Imaging findings. Usually radiological examinations are normal. Occasionally, tracheal or bronchial wall thickening may be seen (arrowheads). Acute Tracheobronchitis ab c

14. Is an other of the Airway-invasive aspergillosis. It also occurs most commonly in neutropenic patients and in patients with AIDS. In this case the infection affects the small airways. Clinical symptoms: are nonspecific. Fever, cough, sputum production, dispnea. Bronchiolitis and Bronchopneumonia

15. Imaging findings. Centrilobular nodules and branching linear and nodular areas of increased attenuation ( “ tree-in-bud ” ). The lesions have a patchy distribution. Bronchopneumonia presents predominantly as peribronchial areas of consolidation (arrows). Aspergillus bronchiolitis and bronchopneumonia are indistinguishable from those caused by other microorganisms. Bronchiolitis and Bronchopneumonia

16. Is characterized by the presence of tissue necrosis and granulomatous inflammation similar to that seen in reactivation tuberculosis. Factors associated with this form of aspergillosis are: chronic illness, diabetes mellitus, alcoholism, corticosteroid therapy, COPD. Clinical symptoms: are often insidious and of long evolution. Chronic cough, sputum production, fever, and constitutional symptoms. Hemoptysis has been reported in 15% of patients. Semi-invasive Aspergillosis

17. Imaging findings. Unilateral or bilateral segmental areas of consolidation with or without cavitations, and multiple nodular areas of increased opacity. The findings progress slowly over months or years. a) Residual cavity in the URL and acute parenchymal condensation. Lineal opacities inside the cavity. b) Worsening of the condensation one month after empiric antibiotic treatment. Now a nodular opacity in the cavity is seeing. Aspergillus was isolated at sputum. c) Resolution of the condensation after antifungal treatment, but with an aspergilloma formation inside the cavity. abc Semi-invasive Aspergillosis

18. It is found in patients with severe neutropenia (intensive chemotherapy, solid organ transplantations and immunosuppressive regimens for autoimmune diseases). Histology: invasion and occlusion of small to medium-sized pulmonary arteries by fungal hyphae and formation of necrotic hemorrhagic nodules or hemorrhagic infarcts. High mortality rate. Clinical symptoms: Are nonspecific. Cough, chest pain, hemoptysis, dyspnea. The clinical diagnosis is difficult. Angioinvasive Aspergillosis

19. Imaging findings. CT findings consist of nodules surrounded by a halo of ground- glass attenuation ( “ halo sign ” ) or pleura-based, wedge-shaped areas of consolidation. These findings correspond to hemorrhagic infarcts. Lesions may present necroses after initiation of treatment with resolution of the neutropenia. Angioinvasive Aspergillosis

20. Conclusion Imaging findings in pulmonary aspergillosis may be nonspecific. In the appropriate clinical setting, imaging findings may suggest and even help establish the specific diagnosis.